Tricuspid Intervention Following Pulmonary Valve Replacement in Adults With Congenital Heart Disease

J Am Coll Cardiol. 2020 Mar 10;75(9):1033-1043. doi: 10.1016/j.jacc.2019.12.053.


Background: Tricuspid regurgitation (TR) is common among adults with corrected tetralogy of Fallot (TOF) or pulmonary stenosis (PS) referred for pulmonary valve replacement (PVR). Yet, combined valve surgery remains controversial.

Objectives: This study sought to evaluate the impact of concomitant tricuspid valve intervention (TVI) on post-operative TR, length of hospital stay, and on a composite endpoint consisting of 7 early adverse events (death, reintervention, cardiac electronic device implantation, infection, thromboembolic event, hemodialysis, and readmission).

Methods: The national Canadian cohort enrolled 542 patients with TOF or PS and mild to severe TR who underwent isolated PVR (66.8%) or PVR+TVI (33.2%). Outcomes were abstracted from charts and compared between groups using multivariable logistic and negative binomial regression.

Results: Median age at reintervention was 35.3 years. Regardless of surgery type, TR decreased by at least 1 echocardiographic grade in 35.4%, 66.9%, and 92.8% of patients with pre-operative mild, moderate, and severe insufficiency. In multivariable analyses, PVR+TVI was associated with an additional 2.3-fold reduction in TR grade (odds ratio [OR]: 0.44; 95% confidence interval [CI]: 0.25 to 0.77) without an increase in early adverse events (OR: 0.85; 95% CI: 0.46 to 1.57) or hospitalization time (incidence rate ratio: 1.17; 95% CI: 0.93 to 1.46). Pre-operative TR severity and presence of transvalvular leads independently predicted post-operative TR. In contrast, early adverse events were strongly associated with atrial tachyarrhythmia, extracardiac arteriopathy, and a high body mass index.

Conclusions: In patients with TOF or PS and significant TR, concomitant TVI is safe and results in better early tricuspid valve competence than isolated PVR.

Keywords: congenital cardiac surgery; pulmonary stenosis; tetralogy of Fallot; tricuspid regurgitation; tricuspid valve repair; tricuspid valve replacement.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Canada / epidemiology
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Heart Defects, Congenital / complications
  • Heart Defects, Congenital / surgery*
  • Heart Valve Prosthesis Implantation / statistics & numerical data*
  • Humans
  • Infant
  • Length of Stay
  • Male
  • Postoperative Complications / epidemiology*
  • Pulmonary Valve Stenosis / complications
  • Pulmonary Valve Stenosis / surgery*
  • Tricuspid Valve Insufficiency / epidemiology
  • Tricuspid Valve Insufficiency / surgery*

Grant support